...While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. Through a series of workshops over the past 18 months, we have tried to define several major categories for a new nosology...

There is no absolute timeline of when these [research] advances might occur. Instead of providing an immediate replacement for DSM and its clinical diagnoses, RDoC is a long-term project to help the research community by defining more biologically based organizational principles for various psychopathologies...

Now, in a move sure to rock psychiatry, psychology and other fields that address mental illness, the director of the National Institutes of Mental Health has announced that the federal agency–which provides grants for research on mental illness–will be “re-orienting its research away from DSM categories.” Thomas Insel’s statement comes just weeks before the scheduled publication of the DSM-V, the fifth edition of the Diagnostic and Statistical Manual.

Note the foreshadowing here: I do think Dr. Insel's timing in announcing the dimensional RDoC was a deliberate attempt to blunt the media circus that will surround the big DSM-5 release at the APA meeting in 2 weeks.

However, Horgan thinks the timing was more related to President's Obama's ambitious new BRAIN Initiative when he says:

NIMH director Insel doesn’t mention it, but I bet his DSM decision is related to the big new Brain Initiative, to which Obama has pledged $100 million next year. Insel, I suspect, is hoping to form an alliance with neuroscience, which now seems to have more political clout than psychiatry.

Do they really think that we won’t notice that the APA and NIMH are working in tandem – that their efforts are coordinated? Do they think we won’t notice that the "cross cutting" dimensional scheme for the DSM-5 that got dropped is the same idea as the RDoC? The articles that have been popping up all day are playing this as Insel’s NIMH throwing the DSM-5 under the bus. No need. The DSM-5 is already under the bus where it belongs.

5 Comments:

The RDoC project has been running for years and the aims have been stated from the start, but the bombshell is not in the fact it exists but the fact that NIMH announced that they will be preferentially funding non-DSM oriented research.

This changes it from and 'interesting side project that we hope will take over from the DSM at some stage' to 'our priority'.

Announcing this, two weeks before the DSM is due to be released is indeed big news, not only for its practical implications but for the rebuke it implies for the APA.

"Its dominance notwithstanding, the DSM diagnostic scheme has not assimilated recent breakthroughs in genetics and neuroscience. Most genetic and neural circuit anomalies appear to link either with multiple DSM diagnostic categories or with narrow subgroups within diagnoses. A questionable assumption that the clusters of self-reported symptoms codified in the DSM define unique and homogeneous disorders could be constraining advances in the biology of mental illness. Consequently inadequate understanding of pathophysiology would in turn hamper the development of better treatments. Notwithstanding these difficulties, there is general consensus at this time that the biology of mental illness is insufficiently developed to support a classification scheme based on the integration of genetics, neuroscience, and psychopathology. The purpose of the RDoC project is to promote such integrative science so that advances in genomics, pathophysiology, and psychology can substantially inform diagnosis."

Basically, I don't think it's surprising that NIMH made this announcement. A lot of time and energy and money went into developing the RDoC framework, which presumably is not a finished product. And some of the major players were involved in the DSM-5 revision from the very beginning.

"This thought-provoking volume—produced as a partnership between the American Psychiatric Association, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse—represents a far-reaching attempt to stimulate research and discussion in the field in preparation for the eventual start of the DSM-V process, still several years hence. The book......

Offers a neuroscience research agenda to guide development of a pathophysiologically based classification for DSM-V, which reviews genetic, brain imaging, postmortem, and animal model research and includes strategic insights for a new research agenda."

Dr. Bruce Cuthbert, Director of the Division of Adult Translational Research and Treatment Development at NIMH, was part of the Phase 1 development team, who published their white papers in the 2002 volume:

"Preparations for DSM-5 revision began in 1999, when the APA collaborated with the NIMH to stimulate the development of a research agenda that would address emerging opportunities relevant to psychiatric nosology."

The DSM-5 revision committee failed to reach its goal of defining more biologically-based diagnostic categories, so RDoC might be viewed as an extension of that work. From Chapter 2 of the 2002 collection (PDF), Neuroscience Research Agenda to Guide Development of a Pathophysiologically Based Classification System:

"At the risk of making an overly broad statement of the status of neurobiological investigations of the major psychiatric disorders noted above, it can be concluded that the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacologic treatment. A primary purpose of this chapter is to review why progress has been so limited and to offer strategic insights that may lead to a more etiologically based diagnostic system. Such an accomplishmentwould represent a highly laudable achievement for psychiatry and would help move the specialty into the mainstream of modern medicine, where etiology and pathophysiology have replaced descriptive symptomatology as the fundamental basis for making diagnostic distinctions."

Finally, this quote from Chapter 1 of the 2002 white paper collection indicates the DSM revision committee didn't exactly expect all of its goals would be reached (PDF):

"Given the relatively short time frame for generating breakthrough research findings between now [1999] and the probable publication of DSM-V in 2010 [2013], it is anticipated that some of the research agendas suggested in these chapters might not bear fruit until the DSM-VI or even DSM-VII revision processes!"

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About Me

Born in West Virginia in 1980, The Neurocritic embarked upon a roadtrip across America at the age of thirteen with his mother. She abandoned him when they reached San Francisco and The Neurocritic descended into a spiral of drug abuse and prostitution. At fifteen, The Neurocritic's psychiatrist encouraged him to start writing as a form of therapy.